Surveillance should ultimately underpin and inform
the diagnosis, treatment, prevention and control of infection.
We argue that this activity could be improved by ensuring that
laboratories are sufficiently well funded to carry out surveillance
work. In addition there is need to use a wider range of innovative
techniques for collating and analysing information. We also recommend
that surveillance of human, animal and food-borne infection should
be more integrated in order to provide important information about
likely outbreaks.

"Surveillance should be the life-blood that
powers clinical practice and public safety" [Dr Black, I
p28].

5.1 Surveillance is the "ongoing systematic
collection, collation, analysis, and interpretation of data and
the dissemination of information to those who need to know in
order that action may be taken" [ref]. It is needed in order
take informed action to counter the spread of infectious disease
at local, national and international levels. It also can determine
the effectiveness of interventions and guide policy in preventing
future outbreaks [Assoc Brit Pharm Ind, I p5; Assoc Clin Microb,
I p15]. We provide an overview of the surveillance process in
relation to influenza in Box 12 (p28).

5.2 Surveillance is mostly based on notifications
of clinical disease and laboratory reports. Doctors are legally
obliged to notify the authorities of certain infections or symptoms
(tuberculosis, food poisoning symptoms for example)[13].
We understand that the Government is currently addressing this
and we look forward to seeing their proposals in the near future.
This is sent to the local authority's "proper officer",
usually the CCDC. Laboratory reports on relevant micro-organisms
are also sent to the CCDC. Reports of other infections are made
on a discretionary basis because of their perceived value, for
example notification of HIV/AIDS.

5.3 The completeness of surveillance does not appear
to depend on a legal requirement. Some conditions for which there
are legal requirements to report are inadequately reported, for
example symptoms of food poisoning. HIV reporting, for which there
is no legal reporting requirement, appears to be effective. It
is important that the system is seen by those providing reports
to produce information relevant to their clinical practice [Seminar,
II p378].

5.4 Microbiology laboratories play a crucial role
in surveillance by providing reports on micro-organisms to CCDCs
and by sending on information and samples for more detailed analysis
to national reference laboratories (managed by the HPA). Representative
information of infection can be effectively provided through a
network of laboratories. These local laboratories involved in
reporting information to national reference laboratories can also
help in responding to emerging threats [Assoc Med Microb II, p70-1].

5.5 We heard that surveillance in England has developed
in a somewhat ad hoc manner [Pub Health Med Env Group,
II p113; Pennington, I p121], but we also heard that the surveillance
network, which was largely based around the Public Health Laboratory
Service (PHLS) (this function has been incorporated in the HPA,
see Box 6) is well regarded internationally [Amyes, I, p1; BioIndustry
Assoc I, p26; USA, II p385].

5.6 However, there are concerns regarding surveillance.
Many of those concerns could be addressed by designing better
information systems and providing information technology and we
address this in chapter six. We turn here to consider other concerns,
particularly that:

· Laboratories,
particularly those run by the NHS, have not always met their obligations
by contributing surveillance information and sending samples on
to reference laboratories;

· Surveillance
information does not provide a representative picture of infection;

· Potential
innovative sources of information and methods for analysing information
are under-used;

· Information
is not shared between all those responsible for surveillance.

5.7 Some of our witnesses were concerned that laboratories
have not always discharged their public health obligations effectively
and may not do so in the future following the transfer of the
majority of former public health laboratories to NHS Trust management[14]
[Bradford MDC, I p34-5; Hawker, II p116, Kesley, Q142]. Under
the new set-up laboratory support for public health at local level
will be provided by these local NHS laboratories with support
from the HPA's regional laboratories[15].

5.8 Laboratories which had a public health focus
will now be managed by NHS Trusts, whose primary focus is the
clinical care of patients [Faculty Pub Health Med, I p55; Lachmann,
Q75; Sheffield, I p151]. Public health and clinical medicine are
by no means incompatible but effective public health may require
laboratories to carry out tests in addition to those that would
be necessary for clinical diagnosis. For example, as part of infection
control, it may be necessary to see whether strains of an infection
are from the same source, or whether people who appear well are
carriers of, or have been exposed to infection.

5.9 Of particular concern is the Department of Health's
statement, that part of NHS laboratory funding will be removed
and redistributed to Primary Care Trusts (PCTs) as part of general
allocations in 2004; and that laboratory funding for public health
work will be guaranteed at its present level only until March
2005 [Minister Blears, Q879; PHLS, II p137]. This would provide
PCTs with significant additional responsibility for public health
aspects of infectious disease [Spencer, Q152; see ch 9].

5.10 We heard that laboratories specialising in food,
water and environmental microbiology provide an essential service,
working closely with local CCDCs, EHOs and the food and water
industries [Bradford MDC, I p34-5; Food Standards Agency, I p64].
We are concerned that the position of this essential component
of the response to infectious disease might be threatened. This
is of particular concern if funding comes through PCTs, which
are primarily concerned with providing clinical services related
to human infection [PHLS, II p137].

5.11 We heard that the ability to direct activity
within a managed network of laboratories, such as existed under
the PHLS, was beneficial [Faculty Pub Health Med, I p53; PHLS
South West, I p133]. Managed networks allow resources to be directed
towards current problems in a coordinated manner. For example,
a wide variety of laboratories across the country could be directed
to sample for a particular organism of concern, as occurred with
E coli O157. Such networks provide surge support.

5.12 We were concerned to find that, given the significant
demands placed on NHS trusts to fulfil their clinical role, there
were no plans as of yet to provide any material incentive for
NHS laboratories to rise to the public health challenge [PHLS,
II p137]. We note that the House of Commons Health Committee report
on Sexual Health[16]
recently expressed concern in relation to the impact of recent
changes to management of laboratories on surveillance of sexually
transmitted infections.

5.13 We believe that it is important that the essential
functions described above are not disrupted as a result of the
recent transfer of some public health laboratories to NHS Trust
control. Changes in management structure and funding streams can
easily cause disruption and this would be unacceptable in relation
to surveillance and the public health function.

5.14 We recommend that the Department of Health
should ensure that Primary Care Trusts provide NHS laboratories
with at least the same level of extra resources for public
health work (including food, water and environmental activity)
that was previously received through the Public Health Laboratory
Service.

5.15 We recommend that the Department of Health
ensures that microbiology laboratories managed by the HPA and
NHS Trusts act in a coordinated manner to deliver effective surveillance
and to provide surge capacity.

5.16 Concerns that surveillance information is unrepresentative
of the incidence of infection fall into three categories: that
there is too much reliance on passive surveillance; that priorities
based on health care need have not been set; and that infection
is under-reported.

5.17 Much surveillance relies on a report of disease
following diagnosis (passive surveillance) [Little, Q376]. An
alternative method of surveillance is to seek patients who display
a set of symptoms (active surveillance). This allows more cases
of infection to be detected rather than relying on formal reports
[Br Infect Soc, I p37; PHLS, II p143].

5.18 Surveillance systems are not based on priorities
or health care need [Inf Control Nurses Assoc, II p176; Williams,
Q383-5]. For example, campylobacter, a bacterial infection causing
diarrhoea, resulted in 63,000 laboratory confirmed cases in 2001
and, according to the Food Standards Agency and Institute of Food
Research, is likely to pose an increasing threat in the foreseeable
future [I, p63, Inst Food Res, II p383]. However, because there
is no priority-setting there is no comprehensive UK laboratory
surveillance of campylobacter [Pennington, I p121]. E coli O157
leads to much more serious symptoms than campylobacter but is
much less common with only about 1,500 infections reported annually,
yet there are two E coli O157 reference laboratories [AcMedSci,
II p35].

5.19 There should also be connections between surveillance
and vaccination. Continued surveillance is necessary to provide
information both about the incidence of side-effects following
vaccination and of the efficacy of vaccination programmes in controlling
infection [CAMR, I p42; Crowcroft, I p45-9; see para 4.5].

5.20 We recommend that the Government should fund
enhanced surveillance of the impact of vaccine programmes on the
incidence of disease particularly when new vaccines are introduced.

5.21 We heard repeatedly that GPs, and other front-line
staff, are an excellent yet under-exploited source of surveillance
information. However, they are often unsure about the link between
contributing to surveillance and being able to improve patient
care [Black, I p30; Beeching, II p49; Faculty Pub Health Med,
I p53Gelletlie, Q241]. Professor Little spoke about the need to
provide primary care workers with a better understanding of the
importance of contributing to surveillance [Q395; see also chapter
7]. In addition, those that provide information should receive
better and more timely feedback about relevant current findings
as a result of surveillance [Beeching, II p49; Monk, Q244; see
ch 6].

5.22 There are some innovative approaches to gathering
information from GPs, such as the population-based Royal College
of General Practice's sentinel surveillance in primary care. This
is based on information about incidence of disease recorded in
GP practices across the UK [Little, Q370]. Sentinel surveillance
in primary care can provide a framework within which more precise
sampling for specific enhanced surveillance objectives can occur
(guided by issues such as socio-demographic representation, seasonal
variation, required precision and cost) [Catchpole Q629; Haworth,
I p75; Little, Q370; Pattison, Q652; Birmingham, II p394].

5.23 We heard that developing enhanced sentinel surveillance
would significantly increase the workload in the practices involved.
It may be that it would be desirable to spread the workload of
enhanced surveillance between practices, with different sentinel
practices taking responsibility for different infections [Birmingham,
II p394].

5.24 We commend the Royal College of General Practice
for its sentinel practice initiatives and would like to see the
scheme extended.

5.25 There is a wide variety of information from
different sources that would be useful to better understand the
prevalence and degree of infection [AcMedSci, II p48; Hawker,
II p117; Inf Control Nurses Assoc, II p176; Little, Q709; Paton,
II p258]. For example, there is some surveillance activity based
on information held by NHS Direct [Zambon, Q214], although we
heard that if this were to include geographical location of callers
it would be improved as it would provide information about geographical
incidence of infection [Black, I p31]

5.26 We note that many people now approach pharmacists
or alternative therapists to obtain advice about ailments. It
would be useful to develop systems to capture information from
sources such as these, as well as others, such as figures of school
absenteeism, attendance at accident and emergency units and water
utility customer complaints [Black, I p34, Griffiths, Q221; Mowat,
I p113; Stewart, II p319].

5.27 Furthermore, many clinicians diagnose infection
on the basis of symptoms rather than laboratory analysis [Spencer,
Q159]. As we suggest in the previous chapter, this is, in cases
of common infection, desirable. However, we heard that the current
surveillance systems do not facilitate reporting on the basis
of symptoms alone [Kelsey, Q161]. Developing systems where syndromes
could be reported would be particularly useful in those cases
where a micro-organism has not yet been isolated, for example
with "severe community acquired pneumonia" [Beeching,
I p49; Black, I p32-3; Zambon, Q193].

5.28 In addition to innovative sources of information
there are a number of powerful analytical techniques used in other
settings such as meteorological and financial forecasting that
are not currently used in fighting infection. They could be adopted
to develop forecasts of outbreaks and spread of infection [PHLS,
p139]. Innovations in this area could improve our understanding
of infection and hence delivery of services and we discuss the
need for research to explore such options in chapter seven.

5.29 In order to develop understanding of infectious
disease it is necessary to gather information not only about incidence
of infection in humans but also about food and water-borne infection
and zoonoses (animal infections that transmit to humans). Furthermore,
infectious disease does not occur in isolation from other countries
[Duerden, Q322; Nicoll, II p160; Salmon, II p 287]. Sharing of
information on an international basis informs knowledge about
infection on a global scale. International surveillance provides
warning about likely occurrence of infection and can therefore
inform, in a timely manner, control measures in this country [Troop,
Q818-9].

5.30 The wide variety of relevant information means
that a number of organisations must play a role in surveillance
[see Box 15]. Responsibility for surveillance across the United
Kingdom is spread between relevant administrative offices. The
HPA has overall responsibility for surveillance in England, some
responsibility in Wales and has a Service Level Agreement with
Northern Ireland. The National Public Health Service for Wales,
with responsibility for surveillance in Wales, reports to the
National Assembly for Wales. The formal links between the HPA
and different Government departments and agencies are as yet unclear
[Salmon, Q699]. We discuss this further in chapter nine.

5.31 A significant amount of evidence flagged up
the importance of zoonoses, warning that "we neglect the
study of animal sources of infection at our peril" [Humphrey,
II p366; Soc General Microb, I p157; Uni Edinburgh, I p169]. We
heard that many emerging human infections are zoonotic and in
order to predict possible outbreaks more accurately it is essential
to have good collaboration between specialists in human and animal
infection [Faculty Pub Health Med, I p56; Pennington, I p121;
Thorns, Q431, see Box 1, 10, 11]. For example we heard in the
USA that it was imperative for experts in animal and human infection
to share surveillance information about West Nile fever (a mosquito
borne infection which is also carried by birds) [USA, II p390].

5.32 Responsibility for surveillance of zoonoses
is spread across a number of different agencies, which rely on
different databases [CAMR, I p42; Thorms, Q438;]. For example,
samples of Salmonella enteritidis phage-type 4 disease (a zoonosis
which causes diarrhoea) may be investigated by one or more microbiology
laboratories run by different agencies, yet these laboratories
cannot share information as they do not have common datasets or
standards [CAMR, I p42; Kealy, I p98].

5.33 Surveillance of infection in animals is usually
driven by concerns over the economic impact of infection in animal
rather than public health [Thorns, Q208]. Therefore, an organism
which does not cause an animal ill-health and has no adverse economic
impact in relation to agriculture, such as campylobacter, is often
not investigated, even though it may cause considerable illness
in humans [Food Standards Agency, I p64]. Some witnesses were
also concerned about the lack of surveillance of companion and
wild animals, which are a significant potential source of infection
[BMA, I p 39; Reilly, Thorns, Q432-3; see Box 10, 11]. This could
be an increasing problem as dogs and cats may now travel overseas
with their owners under the PETS scheme and do not undergo quarantine
on leaving or returning to the UK [BMA, I p39].

5.34 Concern was also expressed that surveillance of food borne
infection should be better integrated [Assoc Brit Pharma Industry,
I p9; O'Brien, I p119]. A variety of organisations are responsible
for reducing risk of food-borne infection. The local authorities,
the Food Standards Agency, CCDCs and others are involved in gathering
information [CAMR, I p42; AcMedSci, II p47; Emery, Monk, Q229;
Humphrey, II p366].

5.35 The Government has recently attempted to coordinate surveillance
across departments through holding some cross-departmental meetings
[Minister Ms Blears, Q840]. We welcome these developments.

5.36 However, the Faculty of Public Health Medicine (a Faculty
of the Royal Colleges of Physicians) when they warn that "despite
the experience of BSE and foot and mouth disease, the degree of
joined-up working needs further improvement" [I p56].The Faculty suggests introducing joint work programmes
on animal and human health which would need budgets for surveillance
and control at regional and local levels.

5.37 We heard repeatedly throughout the inquiry that better exchange
of surveillance information and improving links between experts
and health professionals in animal and human infection was fundamental
to improving response to infectious disease [Kealy, I p97, see
above paragraphs also].

5.38 We recommend that the HPA be provided with resources to
take on specific and primary responsibility for integrating surveillance
related to human, animal and food-borne infection at national,
regional and local levels in order to bridge the gaps that currently
exist between these areas of speciality.